Motivational Interviewing Robert Jope LMHC Disclosures The development

Motivational Interviewing Robert Jope, LMHC

Disclosures The development of these training materials were supported by grant H 79 TI 080209 (PI: S. Becker) from the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, United States Department of Health and Human Services. The views and opinions contained within this document do not necessarily reflect those of the US Department of Health and Human Services, and should not be construed as such.

Housekeeping Agenda Schedule Bathrooms and amenities, cellular phones Guidelines for training Be loose Make mistakes Ask questions Reflect a lot

Two Questions Think of a time that you were in emotional distress over a problem, brought the problem to a friend, and the friend helped you On the yellow sticky note, write a word that describes what they did that was helpful On the green sticky note, write a word that describes how you felt after the interaction

What is Motivational Interviewing? Motivational Interviewing is a collaborative, goaloriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.

What is Motivational Interviewing? Spirit The stance we use to approach the conversation The way we treat the person Skills The types of things we say to the person Strategies The techniques we use to draw out and explore the person’s reasons for change

Motivational Interviewing Spirit “Motivational Interviewing … is more than a set of techniques for doing counseling. It is a way of being with people…”

Motivational Interviewing Spirit Partnership Acceptance Compassion Evocation

Spirit: Partnership Motivational Interviewing is a collaboration between two experts: the person and the helper “Dancing, not wrestling” The helper avoids creating the impression that he or she has the answers The helper suppresses his or her righting reflex The helper is aware of, and honest about, their own values or agenda The helper is profoundly respectful of the person

Spirit: Partnership can be expressed by saying things like: “I’d like to work with you on this. You know yourself – and the problem – much better than I do, and I know things that have worked for others and some of the research that bears on this. ” “How do you see this? What do you think is going on here? ” “What ideas do you have about how to approach this? ” “You’re the expert on what will work for you. ”

Spirit: Acceptance �Absolute worth: the helper regards the person with unconditional positive regard – no judgment �This empowers growth and change �Accurate empathy: the helper strives to see the person’s world through the person’s eyes �This helps the person feel heard and understood �Autonomy support: the helper acknowledges the person’s right to self-direction and choice �This reduces defensiveness and discord �Affirmation: the helper identifies and notes the person’s strengths and efforts �This improves the person’s sense of self-efficacy

Spirit: Acceptance can be expressed by saying things like: �“What to do about this is really up to you. ” �“You’re right. No one can make you change if you don’t want to. ” (don’t follow this with a “…but…”!) Or by using: Reflective statements �Affirmations

Spirit: Compassion

Let us not underestimate how hard it is to listen and to be compassionate. Compassion is hard because it requires the inner disposition to go with others to the place where they are weak, vulnerable, lonely and broken. But this is not our spontaneous response to suffering. What we desire most is to do away with suffering by fleeing from it or finding a quick cure for it. As busy, active, relevant people we want to [make] a real contribution. This means first and foremost doing something to show that our presence makes a difference. And so we ignore our greatest gift, which is our ability to be there, to listen and to enter into solidarity with those who suffer. – Henri Nouwen

The term compassion (com=with and passion=suffering) can literally be interpreted as "with suffering" or coming alongside others in their suffering. When we are willing to be present to and with people in their suffering (e. g. addiction, trauma, woundedness, mental illness, poverty, hard decisions), we provide a tremendous gift to them. Call it acceptance, call it love. Sometimes it's pretty much all someone needs, as it frees and empowers them to move in a new direction. Perhaps you, like me, have been on the receiving end of such compassion at various times in your life, and know what a difference it makes. – Ken Kraybill

One of the hardest things we must sometimes do is to be present to another person's pain without trying to fix it, to simply stand respectfully at the edge of his or her mystery — and misery. Standing there, we feel useless and powerless, which is exactly how a depressed person feels, and our unconscious need as Job's comforters is to reassure ourselves that we are not like the sad soul before us. In an effort to avoid those feelings, I give advice, which sets me — not you — free. If you take my advice, you may get well, and if you don't get well, I did the best I could. If you fail to take my advice, there is nothing I can do about it. Either way, I get relief by distancing myself from you, guilt free. – Parker Palmer

Spirit: Evocation The helper does not operate from the deficit model that is implicit in much of the health and human services fields The helper works to draw out the person’s own wisdom, experience, and expertise in their own change process

Spirit: Evocation can be facilitated by saying things like: “If you decide to change this, how do you think you would go about it? ” “You’ve really put a lot of thought into this. ” (when the person expresses a reason for change) “Tell me more about that. ” Or by: Using evocation strategies Reflecting change talk

Motivational Interviewing Skills

Motivational Interviewing Skills �Open Questions �Affirmations �Reflective Listening �Summaries �Informing and Advising

Skills: Open Questions Any given question is either open or closed Closed questions ask the person for specific information, and would be expected to elicit a short answer Open questions leave a broad latitude for response, inviting the person to elaborate In Motivational Interviewing, most (70%) of the helper’s questions should be open

Skills: Open Questions Great open questions in this model could include: “What ideas have you had about how you might change this? ” “What is the down side of this for you? ” (in response to change talk) “Why? ” Tell me more about that. (yes, that’s a question!) “What are some reasons why you’d want to change? ” “If you did change this, how might your life be different in five years? ”

Skills: Affirmations In Motivational Interviewing, the helper makes specific statements noticing the strengths, values, good intentions, abilities, and efforts of the person To be able to make these statements, the helper maintains a constant “lookout” for material to use to affirm the person

Skills: Affirmations could include statements like: “Standing up to her took a lot of courage. ” “You’ve really made a strong effort to control your blood sugar. ” “It’s important to you to be a good example to your kids. ” “That’s a very creative solution to the problem!” “It looks like your hard work is starting to pay off. ” “You’re very generous. ”

Skills: Reflections The most frequent thing the helper does in a Motivational Interviewing conversation is reflect Reflections are “guesses” about the meaning of what the person has said Sometimes those guesses are safe The best ones are risky Reflection is the best tool to develop and strengthen the person’s change talk

Two Types of Reflections Simple Complex Stay close to the content Create less movement toward change Keep the conversation moving Add meaning or emphasis to the content Create more movement toward change

Complex Reflection: Examples �Continuing the paragraph: adding on to what the person has just said, continuing the story from their perspective �Identifying feeling: using an emotion word to express the person’s feelings �Overshooting: overstating the intensity of the person’s emotion �Undershooting: understating the intensity of the person’s emotion �Double-sided: reflecting both sides of the person’s ambivalence

Guidelines on Reflection Briefer is generally better The goal to shoot for is to have twice as many reflections as questions, and have at least half of all reflections be complex

Skills: Summaries These are pretty much just longer reflections They are used for several purposes Encapsulate what has been said so far Link current content to previous content Transition from one phase of conversation to another The open question “What else? ” is often a good one to use after a summary

Skills: Informing and Advising Before advice or information is offered, the helper should try to evoke it from the person In Motivational Interviewing, advice or information is only offered at the person’s request, or with the person’s permission The helper should always defer to the person on whether the advice or information is applicable The helper should remember to reinforce the person’s freedom of choice

Ask-Offer-Ask 1. Ask the person for information and ideas 1. Reflect their responses 2. Ask permission to provide additional information/ ideas/suggestions 3. List and briefly describe a few items; summarize these together with the items they mentioned 4. Ask the person whether the information or ideas made sense to them, or which of the ideas they might like to try

Practice: Speaker Think of something to talk about that: You’re comfortable sharing with your group You have some ambivalence about You could make a decision on Has some complexity Role playing is permissible, but not preferred

Practice: Helper Your role is to use the spirit and skills of Motivational Interviewing in your conversation with the speaker Try to use twice as many reflections as questions Evoke perspective and reasons for change from the person Suppress the righting reflex! Relax! Take your time with responses, and only say what you want to say Use “do-overs” if you want to

Practice: Coder Use the poker chips to assess the helper’s use of the skills (and spirit) of Motivational Interviewing black for reflections white for questions At the end of the conversation, provide feedback to the helper in a manner consistent with the model

Practice Eight minute conversation between a speaker and a helper, with a coder observing The speaker should do most of the talking The helper is to embody the spirit of Motivational Interviewing AND use twice as many reflections as questions

Change Talk Preparatory Mobilizing Desire statements Ability statements Reason statements Need statements Commitment statements Activation statements Taking steps

Focusing an MI Conversation Establishing topic and direction Verbal Agenda mapping Health wheels Card sorts Specific discussion of focusing helps to make the conversation collaborative

What struck you? What did you notice?

References Miller, W. R. , C’de Baca, J. , Matthews, D. B. , & Wilbourne, P. (2011) Personal Values Card Sort. University of New Mexico. Miller, W. R. & Rollnick, S. (2012) Motivational Interviewing: Helping People Change. Guilford, New York. Miller, W. R. & Rollnick, S. (2002) Motivational Interviewing: Preparing People for Change. Guilford, New York. Moyers, T. B. , Manuel, J. K. , & Ernst, D. (2014). Motivational Interviewing Treatment Integrity Coding Manual 4. 1. Unpublished manual. Moyers, T. B. & Martino, S. (2006) What’s Important in My Life: The Personal Goals and Values Card Sorting Task for Individuals with Schizophrenia. Self-published.